Health inspection·December 22, 2021

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of Resident 61's Observation Detail List Report . Restorative Initial & [and] Quarterly Observation, observation date of 11/30/21 and completed by Staff C, LPN, revealed on page 4, Does Resident require the use of splints, braces, or other devices . splint left hand daily. An observation of Resident #61 on Tuesday 12/21/21 at 5:27 a.m., revealed the resident lying in bed with her left hand clenched into a fist against her body. The resident was not wearing a left-hand splint. An observation of Resident #61 on Tuesday 12/21/21 at 7:38 a.m. revealed the resident sitting in the dining and activities area by the nursing station being served breakfast without a left-hand splint in place. An interview on 12/21/21 at 7:29 a.m., with Staff C, Licensed Practical Nurse (LPN), revealed in the morning time a restorative program list is printed out and given to the restorative Certified Nursing Assistants (CNAs). The duties for the restorative CNA include placing a splint onto a resident per their therapy physician order. Staff C stated splints were normally applied daily to a resident but recalled there was one resident who only got a splint placed onto their person like twice a week for up to four hours or something like that. An interview on 12/21/21 at 9:44 a.m. with Staff D, CNA revealed a restorative splint list was provided to her the morning of 12/21/21. Staff D stated she completed placing all splints onto the required residents. The CNA stated after completing the task, she must go into the online medical kiosk system to mark the task as complete. An observation was made of the CNA's restorative splint program list with a checkmark placed next to Resident #61's name. The CNA stated a checkmark indicated the splint was placed onto the resident. An observation of Resident #61 on Tuesday 12/21/21 at 10:00 a.m. revealed the resident sitting in a high-back chair with a splint on the left hand. During an interview on 12/21/21 at 11:37 a.m., Staff E, Occupational Therapist Registered (OTR) stated an evaluation of a long-term care resident was completed prior to obtaining a physician's order for a splint which was used to address contractures. Staff E, stated how often and when a splint was placed onto a resident, Depends on the flexion contracture. If it [the contracture] is moderate or severe it [a splint] has to be on 6-7 days a week with max [maximum] 4 hours depending on if it [a splint] is tolerated. After the splint is applied, we will then do a skin evaluation . A minor contracture still needs to be monitored to make sure it doesn't become more severe. A follow-up interview on 12/21/21 at 11:49 a.m. with Staff E, OTR revealed a rehabilitation department referral form to restorative nursing would have been completed and passed to the nursing department for a physician order to be generated. A review of Resident #61's physician order stated a splint to be applied 3 x a week without day specifications. Staff E stated it was not within his control to decide what days the splint would be applied. An interview on 12/21/21 at 11:57 a.m. with Staff A, LPN confirmed she was the original LPN who entered the physician order related to the splint for Resident #61. Staff A stated the process was to directly transcribe the therapy department recommendation into a physician order. Once that was completed, the original therapy department recommendation was given to the restorative department to be carried out. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105812 If continuation sheet Page 2 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Care of Avon Park 1213 W Stratford Rd Avon Park, FL 33825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a follow-up interview on 12/21/21 at 12:09 p.m. with Staff C, LPN, Resident #61's splinting physician order was reviewed and revealed that the order did not specify what days the splint should be placed onto the resident. Staff C stated it was not up to the discretion of the CNA for what days a splint was placed onto the resident, normally when an order stated 3 x weekly then it was placed onto the resident Monday's, Wednesdays, and Fridays. Staff C stated the task to place a splint onto a resident should generate in the CNA's task kiosk for check off once it is completed. Staff C stated it was the restorative department's responsibility to clarify a splint physician order and designate what days a resident's splint should be placed onto their person. A record review of Resident #61's POC [point of care] Responses, dated 11/01/2021 to 11/30/2021 and 12/15/2021 to 12/21/2021 revealed under section Restorative Nursing: Splint or Brace Assistance, the task for placing a splint onto Resident #61 was marked as completed on 11/18/2021 and 12/21/2021. An interview was conducted on Tuesday 12/21/21 at 12:20 p.m. with Staff C, LPN and Staff D, CNA. Staff D stated the reason a splint was placed onto Resident #61 today was because normally splints were placed onto a resident daily, so, Staff D just assumed the splint needed to be put onto Resident #61. Staff D stated she did not see the order instructions that the splint was to be placed onto Resident #61 3 x a week. Staff C, LPN stated Resident #61's splinting order for frequency was marked to be placed onto the resident daily, however, the order selection should be every other day for it to generate on Mondays, Wednesdays, and Fridays. Staff C, LPN stated Resident #61 would be placed onto a Tuesday, Thursday, Saturday splinting rotation instead. An interview on 12/21/21 at 12:26 p.m. with the Director of Nursing (DON), confirmed the physician order for Resident #61's splinting program should have been clarified as to what days the splint was placed onto the resident. The DON stated it was not up to the discretion of the CNA to decide what days the splint was placed onto the resident. The DON stated one of the issues was that the task was not selected to generate into the point of care system and therefore would not generate into the CNA task list. A policy review of Rehabilitative Nursing Care, revised December 2020, revealed .Rehabilitative nursing care is provided for each resident admitted during routine ADL [activities of daily living] care and through individualized plans as needed . 1. General rehabilitative nursing care is that which does not require the use of a qualified Professional Therapist to render such care. 2. Nursing personnel are trained in rehabilitative nursing care. Out facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan. 3. The facility's rehabilitative nursing care program is designed to assist each resident to achieve and maintain an optimal level of self-care and independence Assisting residents to adjust to their disabilities, to use their prosthetic devices, splints and other restorative care . An interview on Monday 12/20/21 at 11:18 a.m., with Resident #61's Responsible Party, revealed the resident was completely numb on the left side of the body and was unable to move very much. The Responsible Party stated the resident had a splint, however, I have not seen a brace [splint] in a while on [Resident #61]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105812 If continuation sheet Page 3 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Care of Avon Park 1213 W Stratford Rd Avon Park, FL 33825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure breakfast was delivered to one (Resident #25) of one hemodialysis resident within a timely manner prior to leaving to the dialysis center on one of one observable survey days. Residents Affected - Few Findings included, During an interview on 12/20/21 at 11:55 a.m., Resident #25 stated he went to the dialysis center to receive treatment three days a week: Tuesdays, Thursdays, and Saturdays. Resident #25 stated he left early in the morning and did not always get a meal or snack when going to the dialysis center for treatment. The resident stated upon returning from the dialysis center he was normally really hungry. Resident #25 said, [I] wish that was fixed because I come back starving. Resident #25's Resident Face Sheet revealed medical diagnoses of end stage renal disease, type 2 diabetes, muscle weakness, unspecified protein-calorie malnutrition, and metabolic encephalopathy. Resident #25's MDS, dated [DATE] revealed the resident had a BIMS score of 9, indicating moderate cognitive impairment. A functional status review revealed Resident #25 required extensive assistance from staff with eating, personal hygiene, and dressing. Resident #25's Physician Order Report revealed a dietary order, started on 12/06/21, . RENAL Special Instructions: FOOD IN BOWLS . DOUBLE PORTION BREAKFAST. Further review revealed a general order type, started on 12/11/21 to 12/22/2021 for dialysis on Tuesdays, Thursdays, and Saturday with a transportation pickup time of 6:00 a.m., for a chair time at the dialysis center at 7:00 a.m. Resident #25's Care Plan, revealed problem areas of: 1. Started on 10/30/20, [Resident #25] has hx [history] of cerebral infraction and is at risk for declines with ADL (activities of daily living) related to weakness, impaired mobility endurance varies related to fatigued at times on dialysis days. 2. Started on 10/23/20, [Resident #25] is at nutritional risk related to Dx (diagnosis) of end stage renal disease and on dialysis, dx Diabetes, hx (history) of weight loss. His weight may fluctuate r/t (related to) he is on a diuretic, and dialysis and also on fluid restrictions. Approaches to this problem area included providing a renal diet with double portions at breakfast per orders. 3. Started on 10/26/20, [Resident #25] is at risk for s/s (signs/symptoms) of hypo/hyperglycemia r/t dx of Diabetes. An observation of Resident #25 on Tuesday 12/21/21 at 5:30 a.m. revealed him lying in bed under the covers. All lights in the resident's room were off. Resident #25 eyes were closed without a response to a knock on his bedroom door. An interview on 12/21/2021 at 5:47 a.m. with Staff F, CNA confirmed Resident #25 was a dialysis receiving resident and prior to leaving for treatment she would clean and dress him. Staff F stated sometimes Resident #25 would eat breakfast, and sometimes would not. Staff F stated Resident #25 had not eaten breakfast yet and said, Yes . he goes with a . lunch . we send him with a snack and he gets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105812 If continuation sheet Page 4 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Care of Avon Park 1213 W Stratford Rd Avon Park, FL 33825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm sent with lunch that gets packed . I'm going to get it now. Staff F walked away towards the kitchen area. Staff F returned at 5:55 a.m. carrying two individual serving size packages of cereal and a milk carton. Staff F stated this was going to be Resident #25's breakfast and that the kitchen cook had a note stating the resident was not going to be leaving until 6:30 a.m., so that was why Resident #25 had not been served breakfast yet. Residents Affected - Few An interview on 12/21/21 at 5:58 a.m. with Staff G, Dietary [NAME] revealed the breakfast tray for Resident #25 needed to be ready at 6:30 a.m. Staff G was going to prepare the tray at 6:15ish or 6:20ish. Staff G stated the kitchen had a note stating that the resident would be leaving for dialysis at 6:30 a.m. A review of the note, kept in the kitchen, revealed [Resident #25] Dialysis Tue (Tuesday)-Thurs (Thursday)-Sat (Saturday) leaves @ (at) 6:30 AM . needs early breakfast these days. Thursday was crossed off with Wednesday written above it, indicating the resident would be leaving for dialysis on Wednesday rather than Thursday. Photographic evidence was obtained of the note. On 12/21/21 at 6:00 a.m., two transportation workers were observed walking with a stretcher down the hallway, stopping outside of Resident #25's room. An interview on 12/21/21 at 6:02 a.m. with a Transportation Employee revealed the transportation company was scheduled to pick-up Resident #25 at 6:00 a.m. They usually arrived to the building around 5:55 a.m. or 6:00 a.m. to transport the resident to the dialysis center. The Transportation Employee stated their schedule was to pick up Resident #25 at 6:00 a.m. and did not say before or after breakfast . so even if he doesn't get breakfast, we would take the resident. On 12/21/21 at 6:04 a.m., the Director of Nursing (DON) was observed carrying a breakfast tray with a covered lid into Resident #25 bedroom. On 12/21/21 at 9:18 a.m. an interview with a Charge Nurse at Resident #25's dialysis treatment center revealed Resident #25 was scheduled to be at the facility from 7:00 a.m. to 10:45 a.m. A problem that had been occurring was transportation arrived late to pick up the resident after dialysis treatment, usually get here past 11:00 a.m., closer to 12:00 p.m. So, by the time they get here [Resident #25] can be really cranky because he is hungry so we will give him a lollipop. The Charge Nurse stated due to COVID-19, the dialysis center strongly discouraged eating at the center and did not recommend food be brought in with the resident. So, they recommended a resident ate 30 minutes prior to their assigned chair time. The Charge Nurse stated there had been two occasions this month that she remembered Resident #25 stated he had not eaten breakfast prior to coming to treatment. An interview on 12/21/21 at 9:36 a.m. with the Certified Dietary Manager (CDM) revealed the CNA's would leave a note for the kitchen for what days and times a resident would be going for dialysis treatment. The CDM stated normally, Resident #25 left for the dialysis center at 6:00 a.m. so the breakfast tray should be ready at 5:30 a.m. The CDM provided the note which indicated Resident #25 would be leaving for dialysis at 6:30 a.m. The CDM stated Thursday was crossed off because Resident #25 would be going to dialysis on Wednesday this week due to the holiday schedule. A physician order, started on 12/22/21, revealed DIALYSIS ON TUESDAY, THURSDAY, AND SUNDAY . CHAIR TIME @ 7:00 AM, PICK UP @ 6:00 AM . THIS IS HIS HOLIDAY SCHEDULE [DX [diagnosis]: End stage renal disease]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105812 If continuation sheet Page 5 of 6 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105812 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royal Care of Avon Park 1213 W Stratford Rd Avon Park, FL 33825 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/22/21 at 9:52 a.m. during an interview, the Registered Dietician (RD) stated Resident #25 requested double portions at breakfast. The RD stated a dialysis resident should receive a meal before leaving for the treatment center and upon their return. During an interview with the DON on 12/22/21 at 1:09 p.m., she stated the kitchen would deliver a breakfast meal tray to Resident #25 about 30 minutes prior to the resident's pick-up time and this week we verified that he would be going to dialysis on Tuesdays, Thursdays, and Sunday. The DON stated transportation . cannot just take Resident #25 . if he is eating then they have to wait for him to finish before picking him up. The process was that the nurse would notify the kitchen on what days Resident #25 would be picked up to go for dialysis treatment. A policy review of End-Stage Renal Disease, Care of a Resident with, revised on September 2020, revealed Residents with end-stage renal disease (ESRD), will be treated for according to currently recognized standards of care . 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents . 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the residents care will be managed, including: a. How the care plan will be developed and implemented; b. How information will be exchanged between the facilities . 5. The residence care comprehensive care plan will reflect the residents need related to ESRD/dialysis care. A dialysis contract review, . OUTPATIENT DIALYSIS SERVICES AGREEMENT, signed by the Nursing Home Administrator (NHA) on 3/31/2014, revealed on page 3, 3. Preparation of ESRD Residents. The Nursing Facility shall ensure that ESRD Residents are prepared to spend an extended length of time at the ESRD Dialysis Unit and have received proper nourishment and any medications prescribed, as applicable, before coming to the ESRD Dialysis Unit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105812 If continuation sheet Page 6 of 6